Project: Ghana Emergency Medicine Collaborative

Document Title: Upper Extremity Injuries: Shoulder, Elbow and Wrist

Author(s): Patrick M. Carter (University of Michigan), MD 2012

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 Quibik, Wikimedia Commons

Patrick M. Carter, MD
Instructor
Department of Emergency Medicine
University of Michigan School of Medicine
April 4, 2012 3
 Review key orthopedic injuries of the shoulder, upper arm, elbow,
forearm and wrist
 Fractures
 Dislocations
 Ligamentous Injuries
 Identify key x-ray findings
 Review treatment options for orthopedic disorders of upper
extremity
 Review key complications of upper extremity disorders
 Not a complete review of all upper extremity injuries

4
Gray’s Anatomy, Wikimedia Commons 5
  Less than ½ of the medial end of the clavicle usually articulates
with the sternum
 Joint Stability is dependent on the integrity of the surrounding
ligaments
Sternoclavicular Ligament

Costoclavicular Ligament
Gray’s Anatomy, Wikimedia Commons 6
 Classification
 1st Degree = Sprain
▪ Partial tear of SC and CC ligaments with mild subluxation
 2nd Degree = Subluxation
▪ Complete tear of SC ligament with partial tear of CC
ligament
▪ Clavicle subluxates from the manubrium on x-ray
 3rd Degree = Dislocation
▪ Complete tear of SC and CC ligaments
▪ Complete dislocation of clavicle from the manubrium
▪ Anterior > Posterior
▪ Posterior = True Emergency – 25% will have concurrent life-
threatening injuries to adjacent mediastinal structures

7
 Mechanism of Injury
 Direct force applied to the medial end of the clavicle
 Indirect force to the shoulder with the shoulder rolled either forward or
backward that tears medial ligaments
 Symptoms/Signs
 Pain and swelling over the SC joint
 Pain with movement of shoulder
 Anterior Dislocation = Prominent medial clavicle anterior to sternum
 Posterior Dislocation = Clavicle may not be palpable, may be subtle
 Diagnosis
 X-ray
 CT scan (Diagnostic Study of Choice if concern for underlying
structures)

8
 Treatment
 1st Degree = Sling, Analgesia, Ice
 2nd Degree
▪ Sling or Figure of Eight Clavicular Strap, Orthopedic Follow-up
 3rd Degree
▪ Anterior Dislocation
▪ Uncomplicated anterior dislocations often don’t require reduction
▪ Sling or Figure of Eight, Analgesia and outpatient follow-up
▪ Posterior Dislocation
▪ Reduction often necessary due to underlying injury
▪ Closed reduction in OR
▪ Reduction
 Towel roll between scapula
 Traction applied to arm
 Towel clip on clavicle with traction to reduce
9
 Acromioclavicular
Gray’s Anatomy, Wikimedia Commons
 AC Joint Anatomy Ligament
 Mechanism of Injury
 Fall on outstretched arm with
transmission to AC joint
 Fall on shoulder with arm
adducted (most common)
 Scapula and Shoulder girdle
driven inferiorly with clavicle in
normal position
 Signs/Symptoms
 Joint Tenderness
 Swelling over the joint
 Pain with movement of affected
extremity
 Displacement of clavicle Coracoclavicular Ligaments
- Coracoacromial ligament
- Trapezoid Coracoclavicular ligament
- Conoid Coracoclavicular ligament 10
 AC Joint Injury Classification
 Tossy and Allman Classification (Types 1-3)
 Rockwood Classification (Types 4-6)
 Classification
 Type 1 = Sprain = Partial tear of AC ligament, No CC ligament
injury
 Type 2 = Subluxation = Complete tear of AC ligament, CC
ligament stretched or incompletely torn
 Type 3 = Dislocation = Complete tears of AC and CC ligaments
with displacement of clavicle
 Direction of displacement defines types 4-6
▪ Type IV = Posterior displacement in or through trapezius
▪ Type V = Superior displacement (more serious type 3 injury)
▪ Type VI = Inferior displacement of clavicle behind biceps tendon

11
Source: Steve Oh, 2004
12
 X-rays
 AP views of clavicle usually sufficient
 Stress views not commonly used anymore and do not alter course of
treatment
 Axillary views necessary for posterior dislocation identification (Type 4)
 Findings
▪ Type 1 = Radiographically normal
▪ Type 2 = Increased distance between clavicle and acromion (< 1 cm)
▪ Type 3 = Increased distance between the clavicle and acromion (> 1 cm)
▪ Type 4-6 = Defined by displacement
 Treatment
 Type 1-2 = Sling x 1-2 weeks, Rest, Ice, Analgesia, Early ROM 7-14
days
 Type 3 = Immobilize in sling, Prompt orthopedic referral
▪ Controversy regarding operative vs. conservative treatment options
▪ Shift towards conservative treatment
 Type 4-6 = Sling, Prompt orthopedic referral, Likely will require surgical
management

13
Root4(one), Wikimedia Commons Source Undetermined

14
 Clavicle
 Provides support and mobility for upper
extremity functions
 Protects adjacent structures
 Mechanism of Injury
 Direct blow to clavicle
 Fall on outstretched shoulder
Magnus Manske, Wikimedia Commons
 Symptoms/Signs
 Pain, Swelling and Deformity
 Arm is held inward and downward and
supported by other extremity
 Open fractures result from severe tenting
and piercing of overlying skin
 Imaging
 CXR or Clavicle films
 Children may have a greenstick fracture
without definite fracture on x-ray imaging
15
Source Undetermined
 Allman Classification
 Middle 1/3 (80%)
▪ Most common area to fracture Allman Classification
▪ Especially in children
 Distal 1/3 (15%)
▪ Often associated with ruptured
CC joint with medial elevation
▪ May require operative
intervention to avoid non-union Group III Group I Group II
 Medial 1/3 (5%) ~Medial 1/3 ~Middle 1/3 ~Distal 1/3
▪ Uncommon ~3%-6% ~69%-85% ~12%-28%
▪ Requires strong injury forces
▪ Higher association with Image adapted from Anatomagraphy, Wikimedia
intrathoracic injury Commons

▪ (e.g Subclavian Artery/Vein injury)

16
Source Undetermined

17
 Emergency Orthopedic Consultation
 Open Fractures
 Fractures with neurovascular injuries
 Fractures with significant tenting at high risk for converting to open
 Indications for Surgical Repair
 Displaced distal third
 Open
 Bilateral
 Neurovascular injury
 Treatment = Sling, Orthopedic Follow-up
 Non-operative management is successful in 90%
 Middle 1/3 Clavicle Non-union risk factors
 Shortening > 2 cm
 Comminuted fracture
 Elderly female
 Displaced fracture
 Significant associated trauma
18
 Scapula
 Links the axial skeleton to the upper extremity
 Stabilizing platform for the motion of the arm
 1% cases of blunt trauma have scapular fracture
 3-5% of shoulder injuries
 Mechanism of Injury Glenoid
 Direct blow to the scapula
 Trauma to the shoulder
 Fall on an outstretched arm
 Clinical Presentation
 Localized pain over the scapula
 Ipsilateral arm held in adduction Body Neck
 Any movement of arm exacerbates pain
 High association with other intrathoracic injuries (>75%)
 Due to high degree of energy required for fracture
 Pulmonary contusion > 50% of cases
 Pneumothorax, Rib fractures commonly associated
Gray’s Anatomy, Wikimedia Commons 19
 Classification
 Anatomic Location
 Body = 50-60%
 Neck = 25%
 Imaging
 Shoulder/Dedicated
Scapular Series
▪ AP/Lateral/Axillary
 Axillary views help identify
fractures:
▪ Glenoid fossa
▪ Acromion
▪ Coracoid Process
 Consider CXR/Chest CT to
Gray’s Anatomy, Wikimedia
rule out associated injuries Commons

20
 Treatment
 Sling, Ice, Analgesia
 Immobilization
 Early ROM exercises
 Orthopedic Referral for ORIF
▪ Glenoid articular surface fractures
with displacement
▪ Scapular neck fractures with
angulation
▪ Acromial fractures associated with
rotator cuff injuries

Source Undetermined

21
 Shoulder dislocation = Most common dislocation in the ED
 Classification
 Anterior (95-97%)
▪ Subcoricoid, Subglenoid, Subclavicular, Intrathroracic
 Posterior (2-3%)
▪ Most commonly missed dislocation in the ED
▪ Association with Seizure, Electric Shock/lightening injuries
 Inferior (Luxatio Erecta)
 Superior (Very Rare)
 Mechanism of Injury
 Anterior = Abduction, Extension and External Rotation with force applied
to shoulder
 Posterior = Indirect force with forceful internal rotation and adduction

22
 Clinical Presentation
 “Squared off” Shoulder
 Patient resists abduction and internal
rotation
 Humeral head palpable anteriorly
 Must test axillary nerve
function/sensation Source Undetermined
 Quebec Decision Rule
 Radiographs needed for:
▪ Age > 40 and humeral ecchymosis
▪ Age > 40 and 1st dislocation
▪ Age < 40 and mechanism other than fall
from standing height or lower
 Failed to be validated due to low
sensitivity (CJEM 2011)
 Recurrent Shoulder dislocations
 Radiographs
 AP/Lateral/Y-view
Source Undetermined 23
 Clinical Presentation
 Prominence of posterior shoulder
 Anterior flatness
 Unable to externally rotate or abduct the
affected arm
 Radiography
 AP Radiograph Source Undetermined
▪ “Light Bulb Sign”
▪ Internal rotation of the humerus
 Y view
▪ Diagnostic for posterior dislocation

Source Undetermined 24
 Inferior Shoulder Dislocation
 Hyperabduction force
 Levers humerus against the acromion
tearing inferior capsule
 Forces humeral head out inferiorly
 Clinical Presentation
 Humerus is fully abducted, elbow
flexed, hand behind the head
 Humeral head palpated on lateral chest
wall
 Frequently associated with:
 Soft tissue injuries/rotator cuff tears
 Fractures of humeral head
 Neurovascular compression injury is
common Source Undetermined

25
 Treatment
 Reduction using a variety of techniques
▪ Success rate = 70-96% regardless of
technique
 Shoulder dislocation with associated
humeral head fracture typically require
orthopedic consultation and may require
operative repair
 Neurovascular exam pre- and post
reduction
 Procedural Sedation if initial attempts
unsuccessful
 Intra-articular injection of 10-20 cc
lidocaine alternative to procedural
sedation
 After reduction, patient should be placed Nevit Dilman, Wikimedia Commons
in shoulder immobilizer and orthopedic
follow-up arranged

26
 External Rotation
 Hennepin Technique
 Gentle external rotation
 Followed by slow
abduction of arm
 Reduction typically
complete prior to reaching
coronal plane
 78% success rate
 Procedural sedation rarely Source: University of Hawaii School of Medicine

needed

27
 Modified Hippocratic or Traction-Countertraction Technique

Source: University of Hawaii School of Medicine

28
 Scapular Manipulation
 Technique
▪ Seated Position
▪ Steady forward traction on wrist
parallel to floor
▪ Rotate inferior tip of scapula
medially and superior aspect Source: University of Hawaii School of Medicine
laterally
 96% Success rate
 Requires two people
 Borders of scapula can be
difficult to identify in obese
patients
 Rarely requires sedation

Source: University of Hawaii School of Medicine 29

 Stimpson or Hanging Weight Technique

30
Source: University of Hawaii School of Medicine
 Complications
 Recurrent dislocation (Most Common)
▪ < 20 years old: > 90%
▪ > 40 years old: 10-15%
 Bony Injuries
▪ Hill-Sachs Deformity
▪ Compression fracture or groove of posterolateral aspect of humeral head
▪ Results from impact of humeral head on the anterior glenoid rim as it dislocates or reduces
▪ Avulsion of greater tuberosity (Higher incidence > 45 years old)
▪ Bankart’s Fracture = Fracture of the anterior glenoid lip
 Nerve Injuries (10-25% dislocations)
▪ Most often are traction related neuropraxias and resolve spontaneously
▪ Axillary nerve (most common) or Musculocutaneous nerve
 Rotator Cuff Tears
▪ 86% of patients > 40 years will have associated rotator cuff tear
 Axillary Artery Injury (rare)
▪ Elderly patients with weak pulse
▪ Rapidly expanding hematoma
31
 Hill Sachs Deformity  Bankart’s Lesion/Fracture

http://www.mypacs.net/repos/mpv3_repo/viz/ful
l/18712/935613.jpg
Hellerhoff, Wikimedia Commons
RSatUSZ, Wikimedia Commons

32
 Rotator cuff = 4 muscles that insert tendons into the greater and lesser tuberosity
 SITS MUSCLES = Subscapularis, Supraspinatous, Infraspinatous, Teres minor
 Mechanisms of Injury
 Acute tear = Forceful abduction of the arm against resistance (e.g. fall on outstretched arm)
 Chronic teat = 90% = Results from subacromial impingement and decreased blood supply to
the tendons (worsens as patient ages)
 Clinical Picture
 Typically affects males at 40 y/o or later
 Pain over anterior aspect of shoulder, tearing quality to pain, typically worse at night
 PE with weak and painful abduction or inability to initiate abduction (if complete tear)
 Tenderness on palpation of supraspinatous over greater tuberosity
 Imaging
 In ED, plain film x-rays indicated to exclude fracture and may show degenerative changes
and superior displacement of humeral head
 MRI is diagnostic (not typically done in ED setting)
 Treatment
 Sling Immobilization, Analgesia, Ortho Referral
 Complete tears require early surgical repair (< 3 weeks)
 Chronic tears are managed with immobilization, analgesia and orthopedic follow-up for
rehabilitation exercises and possible steroid injection

33
 Proximal Humerus Fractures
 Common in elderly patients with osteoporosis
 Mechanism of Injury = Fall on outstretched hand with elbow extended
 Clinical Presentation
▪ Pain, swelling and tenderness around the shoulder
▪ Brachial plexus and axillary arteries injuries
▪ Higher incidence (>50%) in displaced fractures
 Neer Classification guides treatment
▪ Fractures separate humerus into 4 fragments by epiphyseal lines
▪ Displacement > 1 cm or angulation > 45 degrees defines a fragment as a
“separate part” when fractures occur
▪ If none of fragments are displaced > 1cm, fracture is termed 1 part
 Treatment
▪ One part fractures (85%) = immobilization in sling/swathe, ice, analgesics,
orthopedic referral
▪ Two/Three/Four part fractures = Orthopedic Consultation

34
 1
3
2

Fragments of Humerus Head

Articular surface of humeral head
Greater tubercle
James Heilman, MD, Wikimedia Commons
Lesser tubercle
Shaft of humerus
Gray’s Anatomy,
Wikimedia Commons
35
 Typically involve middle 1/3 of the humeral shaft
 Mechanism of Injury
 Direct Blow (Most common)
 Fall on outstretched arm or elbow
 Pathologic Fracture (e.g. breast cancer)
 Clinical Presentation
 Pain and deformity over affected region
 Associated Injuries
▪ Radial Nerve injury = Wrist Drop (10-20%)
▪ Neuropraxia will often resolve spontaneously
▪ Nerve palsy after manipulation or splinting is due to nerve entrapment and must be
immediately explored by orthopedic surgery
▪ Ulnar and Median nerve injury (less common)
▪ Brachial Artery Injury

36
 Imaging = Standard x-ray imaging
 Treatment
 Non-operative Management (most common)
▪ Simple Sling and Swath adequate for ED patients
▪ Closed treatment options
▪ Coaptation splint (sugar tong)
▪ Hanging cast
▪ External fixation
 Operative management
▪ Neurovascular compromise, pathologic fractures
 Complications
 Neurovascular injury
Bill Rhodes, Wikimedia Commons
 Delayed union
 Adhesive capsulitis

37
 Proximal or distal biceps tendon rupture
 Mechanism of Injury = Sudden or prolonged
contraction against resistance in middle aged
or elderly patients
 Clinical Presentation
 “Snap” or “Pop” typically described Gray’s Anatomy, Wikimedia
 Pain, swelling, tenderness over site of tendon Commons

rupture
 Flexion of elbow = Mid-arm ball
 Loss of strength sometimes minimal
 X-rays to exclude avulsion fracture
 ED Treatment
 Sling, Ice, Analgesia, Orthopedic referral Patenthalse, Wikimedia Commons
 Surgical repair for young, active patients

38
Source Undetermined 39
 Anterior Humeral Line
• Normal = Middle of capitellum
• Abnormal = Anterior 1/3 of
capitellum or completely anterior
Anterior Fat Pad
“Sail Sign”

Source Undetermined

Radial-Capitellar Line
•Normal = Transects
Posterior Fat Pad middle of capitellum
(Never normal)

Source Undetermined

Hellerhoff, Wikimedia Commons

40
 Supracondylar Extension Fractures
 Most Common Type
 Mechanism of injury
▪ Fall on outstretched arm with elbow in extension
 Imaging
▪ Distal humerus fractures and humeral fragment displaced posteriorly
▪ Sharp fracture fragments displaced anteriorly with potential for injury
of brachial artery and median nerve
 Treatment
▪ Non-displaced fracture (Rare) = Immobilization in posterior splint
▪ May be discharged home with close follow-up
▪ Displaced fracture
▪ Orthopedic Consultation and reduction
▪ Patients with displaced fractures or significant soft tissue swelling require
admission for observation

41
 Supracondylar Flexion Fractures (rare)
 Mechanism of Injury
▪ Direct blow to posterior aspect of flexed elbow
 Fractures are frequently open
 Imaging = Distal humerus fracture displaced anteriorly
 Treatment
▪ Non-displaced fractures
▪ Splint immobilization and early orthopedic follow-up
▪ Displaced fractures
▪ Orthopedic consultation for reduction
▪ Patients with displacement and soft tissue swelling require admission

42
 Extension Type Fracture Flexion Type Fracture

Source Undetermined Source Undetermined Source Undetermined

43
 Early Complications
 Neurologic (7%)
▪ Results from traction, direct trauma or nerve ischemia
▪ Radial Nerve (Posterior-medial displacement)
▪ Median Nerve (Posterior-lateral displacement)
▪ Ulnar Nerve (Uncommon)
▪ Anterior Interosseous Nerve Injuries
▪ High incidence with supracondylar fractures
▪ No sensory component, Motor component must be tested (“OK sign”)
 Vascular Entrapment (Brachial Artery)
 Late Complications
 Non-union/Mal-union
 Loss of mobility

44
 Compartment syndrome of the forearm
 Complication of elbow/forearm fractures
 Increased compartment pressure results in ischemia of muscles of
forearm, typically flexor compartment
 Patient complains of pain out of proportion of injury, digit swelling
and paresthesias
 Also consider in any patient presenting with pain and numbness in
hand after casting has been performed
 Irreversible damage in 6 hours (see image)
 Treatment
 Removal of cast
 Surgical decompression with fasciotomy

Source Undetermined

45
 Most common fractures of the elbow Source Undetermined
 Mechanism of Injury = Fall on outstretched hand
 Clinical Finding = Tenderness and swelling over the radial head
 Imaging
 May not be seen on initial x-ray or may be subtle on x-ray
 Evaluate for anterior or posterior fat pad which suggests diagnosis
 Associated Injuries
 Essex-Lopresti Lesion
▪ Disruption of fibrocartilage of the wrist and interosseus membrane
▪ Distal radial-ulnar dissociation
 Articular surface of capitellum frequently also injured
 Treatment
 Non-displaced = Sling, Ortho follow-up
 Comminuted/Displaced Fractures require urgent orthopedic referral
within 24 hours

46
 Nursemaid’s elbow = Subluxation of
radial head beneath the annular
ligament
 Mechanism of injury = Longitudinal
traction on hand or forearm with
arm in pronation
 X-rays not necessary
 Treatment = Reduction
 Thumb over radial head with
concurrent supination of forearm and David Tan, Flickr
flexion of elbow
 Extension and pronation (another
option for reduction)

47
 flexion

hyperpronation supination

Therese Clutario, Wikimedia Commons

48
 Third most common joint dislocation
 Posterolateral (90%)
 Mechanism of Injury = Fall on outstretched hand
 Clinical Findings
▪ Marked swelling with loss of landmarks
▪ Posterior prominence of olecranon
 Immediate consideration must be given to neurovascular status
▪ Ulnar or Median Nerve injury common (8-21%)
▪ Brachial artery injury (5-13%)
 Associated fractures (30-60%) of coronoid process and radial head
 Terrible triad injury = elbow dislocation + radial head and coronoid
fracture (unstable)
 Anterior (Uncommon)
 Mechanism of Injury = Blow to Olecranon with elbow in flexion
 Associated Injuries = Much higher incidence of vascular impingement

49
Anterior Elbow Dislocation Posterior Elbow Dislocation

http://tw.myblog.yahoo.com/doctor--
anjenli/article?mid=776&prev=778&next=774&l=f&fid=79

Source Undetermined Source Undetermined

50
 Elbow Reduction
 Immobilize humerus
 Apply traction at wrist
 Slight flexion of the elbow
 Posterior pressure on olecranon
 Post-Reduction
 Long Term Complications
 Post-traumatic arthritis
 Joint instability

51
 Fracture of both ulnar and radius
 Usually displaced fracture
 Mechanism of Injury
 Direct blow to forearm
 Associated Injury
 Peripheral Nerve Deficits
▪ Uncommon in most closed injuries
▪ More common with open fractures
 Development of compartment syndrome
 Treatment
 Displaced – ORIF
 Complications
 Compartment Syndrome
 Malunion
Source Undetermined

52
 Isolated fracture of ulnar
shaft
 Mechanism
 Direct blow to ulna
 Patient raising forearm to
protect face
 Treatment
 Non-displaced
▪ Immobilization in splint
 Displaced
▪ >10 degrees angulation
▪ Displacement > 50% of ulna
▪ Orthopedic consultation - ORIF
Source Undetermined

53
 Distal Radius Fracture
 Distal radio-ulnar
dislocation
 Reverse Monteggia’s fx
 Mechanism of Injury
 Direct blow to back of wrist
 Fall on outstretched hand
 Complication = Ulnar
nerve injury
 Treatment = ORIF Th. Zimmermann, Wikimedia Commons
http://www.learningradiology.com/caseofweek/ca
seoftheweekpix2/cow157lg.jpg

54
 Proximal 1/3 Ulnar Fracture
 Dislocation of radial head
 Mechanism of Injury = Direct blow
to posterior aspect of ulna
 Fall on outstretched hand
 Imaging
 Elbow/Forearm x-rays
 Radial head dislocation missed in
25% of cases
 Carefully examine the alignment of
radial head
 Associated Injury = Radial Nerve
Injury
 Treatment
 ORIF Jane Agnes, Wikimedia Commons

 Closed Reduction/Splinting

55
Galeazzi G M
Radial Fracture
Ulnar Fracture
Monteggia
Patrick Carter, University of Michigan
R U
Patrick Carter, University of Michigan

56
 Transverse fracture of distal radius with dorsal displacement of distal
fragment
 Mechanism = Fall on outstretched hand
 Most common fracture in adults > 50 years old
 Exam = Classic Dinner Fork Deformity
 Associated Injuries
 Ulnar styloid fracture
 Median Nerve Injury
 Unstable Fractures
 >20 degrees angulation, intra-articular involvement, comminuted fractures or
> 1 cm of shortening
 Treatment
 Non-displaced Fracture
▪ Sugar Tong Splint, Referral to Orthopedic Surgery
 Displaced Fracture
▪ Reduction – Finger traps and manipulation under procedural sedation or with
hematoma block
▪ Immobilization in Sugar tong splint
▪ Referral to Orthopedic Surgery

57
 Transverse fracture of distal
radius with volar displacement
 Mechanism = Fall on
outstretched arm with forearm
in supination
 Associated Injury = Median
Nerve Injury
 Treatment
 Reduction with finger traps and
manipulation
 Immobilization in sugar tong or
long arm splint
 Orthopedic referral

58
 Colles Fracture  Smith Fracture

Source Undetermined
Lucien Monfils, Wikimedia Commons

Goals of Reduction:
* Restore volar tilt
* Radial Inclination
* Proper radial length 59
Source Undetermined

60
 Scaphoid Fracture
 Most common carpal bone fracture
 Mechanism = fall on outstretched hand or axial load to thumb
 2/3 of fracture in waist of scaphoid
 Imaging – Initial x-rays may fail to demonstrate fracture
▪ > 10% of cases
▪ Repeat Imaging in 2 weeks will often show fracture
 Clinical findings = tenderness in anatomical snuff box
 Treatment
▪ Non-displaced or clinically suspected fracture
▪ Thumb spica Splint
▪ Displaced fractures will require ORIF
▪ Complications
▪ Avascular necrosis of proximal fragment -> arthritis
▪ Delayed union or malunion

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Gilo1969, Wikimedia Commons

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 Triquetrum Fracture (2nd most common)
 Mechanism = Fall on outstretched hand
 Body fracture or avulsion chip fractures
 Exam = Tenderness on palpation distal to ulnar styloid on dorsal aspect of
wrist, painful flexion
 Avulsion fracture best visualized on lateral or oblique view of wrist
 Treatment = Volar splint, Orthopedic referral
 Lunate Fracture
 Mechanism = Fall on outstretched hand
 Exam = Pain over mid-dorsum of wrist increased with axial loading of 3rd
digit
 Vascular supply is through distal end of bone -> high risk for avascular
necrosis of the proximal portion
 Plain x-rays are often normal
 Treatment = Immobilization in thumb spica splint, orthopedic referral
 Complications
▪ Kienbock’s disease = Avascular necrosis of proximal segment
▪ Chronic pain, decreased grip strength, osteoarthritis

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 Triquetrum Fracture  Lunate Fracture

Hellerhoff, Wikimedia Commons

Source Undetermined
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 Lunate is at the center of the carpal bones
 Majority of ligamentous injuries are centered on the lunate
 Injuries are from forceful dorsiflexion of wrist
 Degree of force determines severity of injury
▪ Spectrum from isolated tear to dislocations
 Spectrum of ligamentous injuries
 Scapholunate ligament instability
 Triquetrolunate ligament instability
 Perilunate and Lunate dislocations

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 Scapholunate ligament binds the scaphoid and lunate together
 Most common ligamentous injury of hand
 Commonly missed
 Pain with wrist hyperextension, snapping or clicking sensation with
radial/ulnar deviation
 Radiographic signs
 Scaphoid is foreshortened and has a dense ring shaped image around
its distal edge (signet or cortical ring sign)
 Widening of space between the lunate/scaphoid
▪ > 3 mm, Terry Thomas sign
 Treatment
 Thumb spica or radial gutter splint
 Orthopedic Referral

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 Terry Thomas and Signet Ring Sign

Source Undetermined
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 Perilunate and lunate dislocations are the result of the most severe
carpal ligamentous injury
 Mechanism of Injury = Violent Hyperextension usually combined with a
fall from height or motor vehicle crash
 Clinical examination
 Generalized swelling, pain and tenderness over wrist
 May be deceiving with no evidence of gross deformity
 Radiographic evaluation is key to diagnosis
 Treatment = Orthopedic Consultation
 Treatment is dependent on severity of injury
 Closed reduction and long-arm immobilization if possible
 Open, unstable and irreducible dislocations require OR
 Some orthopedists take all dislocations to OR
 Complications
 Degenerative Arthritis
 Delayed union/Malunion/Non-union
 Avascular necrosis

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 Lunate

Source Undetermined

 4 C’s Need to line up on normal x-ray

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 Lunate Dislocation  Peri-lunate Dislocation
 Capitate is centered over the  Lunate is centered over the
radius and the lunate is tilted out radius and capitate is tilted out
 Spilled Tea cup deformity  Associated with scaphoid fx

Source: Radiology
Source: Radiology Assistant
Assistant

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 Carpal Tunnel Syndrome
 Entrapment of Median nerve
 Tinel’s sign = Tapping over volar wrist produces paresthesias
 Phalen’s sign = Hyperflexion of wrist = Paresthesias
 Risk Factors = Pregnancy, Hypothyroid, DM, RA
 Treatment = Splinting, Rest, Surgical Decompression
 DeQuervain’s Tenosynovitis
 Overuse syndrome with inflammation of extensor tendons of thumb
 Characterized by pain along radial aspect of wrist that is exacerbated with
use of thumb
 Finkelstein’s test = Ulnar deviation of fisted hand produces pain
 Treatment = NSAIDS, Splint, Rest
 Guyon’s Canal Syndrome
 Ulnar nerve entrapment syndrome
 Numbness and tingling in ring and small finger
 Causes = repetitive trauma (handle bar neuropathy), cyst
 Treatment = Splint, Surgical Decompression

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